WHAT IS KNOWN AND OBJECTIVE: Medication reconciliation is recognized as an important tool for the prevention of medication discrepancies and subsequent patient harm at care transitions. However, there is inconclusive evidence as to the impact of medication reconciliation at hospital transitions overall, as well as pharmacy-led medication reconciliation services. This review sought to evaluate the impact of pharmacy-led medication reconciliation interventions on medication discrepancies at hospital transitions and to categorize these interventions as single transition interventions or multiple transitions interventions...

OBJECTIVE: Effective stroke care does not end with acute treatment during hospitalization, but extends through rehabilitation and secondary stroke prevention. In transitions across care environments, stroke patients are vulnerable to errors in communication of diagnosis and treatment. This study aimed to demonstrate that formalized communication between the neurology team and the rehabilitation medicine team would promote secondary stroke prevention and minimize interruptions during rehabilitation...

BACKGROUND: Medication discrepancies have the potential to cause harm. Medication reconciliation by clinical pharmacists aims to prevent discrepancies and other drug-related problems. OBJECTIVE: To determine how often discrepancies in the physician-acquired medication history result in discrepancies during hospitalization and at discharge. Secondary objectives were to determine the influence of clinical pharmacists' interventions on discrepancies and to investigate possible patient-related determinants for experiencing discrepancies...

AIMS: To determine the incidence of unintended medication discrepancies in paediatric patients at the time of hospital admission; evaluate the process of medicines reconciliation; assess the benefit of medicines reconciliation in preventing clinical harm. METHOD: A 5 month prospective multisite study. Pharmacists at four English hospitals conducted admission medicines reconciliation in children using a standardised data collection form. A discrepancy was defined as a difference between the patient's preadmission medication (PAM), compared with the initial admission medication orders written by the hospital doctor...

Medication reconciliation is an important process in reducing medication errors in many countries. Canada, the USA, and UK have incorporated medication reconciliation as a priority area for national patient safety initiatives and goals. The UK national guidance excludes the pediatric population. The aim of this review was to explore the occurrence of medication discrepancies in the pediatric population. The primary objective was to identify studies reporting the rate and clinical significance of the discrepancies and the secondary objective was to ascertain whether any specific interventions have been used for medication reconciliation in pediatric settings...

BACKGROUND: Medication reconciliation has been recognized as an important process in care transitions to prevent adverse health outcomes. Because older adults have multiple comorbid conditions and use multiple medications, they are more likely to experience complicated transitions between acute and long-term care settings. Hence, it is important to develop effective interventions to protect older adults at transition points of care. OBJECTIVE: To systematically review the literature and evaluate studies performing medication reconciliation interventions in patients transferred to and from long-term care settings...

BACKGROUND: Medication errors at the time of hospital admission and discharge are common and can lead to preventable adverse drug events. The objective of this study was to describe the potential impact of a medication reconciliation process to identify and rectify medication errors at the time of hospital admission and discharge. METHODS: Sixty randomly selected patients were prospectively enrolled at the time of admission to a Canadian community hospital. At admission, patients' medication orders were compared with pre-admission medication use based on medication vials and interviews with patients, caregivers, and/or outpatient healthcare providers...

Seamless care is the desirable continuity of care delivered to a patient in the healthcare system across the spectrum of caregivers and their environments. Medication Reconciliation is one component of seamless pharmaceutical care. A randomized controlled trial, carried out over nine months with a six-month follow-up period, investigated the impact of a pharmacist-directed seamless care service. Intervention patients admitted to one of two general medicine units were subjected to a comprehensive seamless care discharge process as they were discharged from a regional, academically affiliated hospital in Moncton, NB...

Medication reconciliation is a crucial step in safe care, but it is often done inconsistently or inadequately, or missed altogether. This can be dangerous and even deadly for patients, and expensive for the system. In this article, the authors discuss the current status of medication reconciliation in Canada, barriers to its implementation and steps healthcare organizations across the country are taking to introduce medication reconciliation. They conclude by outlining ways that provincial and territorial governments could re-energize work on medication reconciliation...

BACKGROUND: Medication errors may occur more frequently at discharge, making discharge counselling a vital facet of medication reconciliation. Discharge counselling is a recognized patient safety initiative for which pharmacists have appropriate expertise, but data are lacking about the barriers to provision of this service to adult inpatients by pharmacists. OBJECTIVES: To determine the proportion of eligible patients who received discharge counselling, to quantify perceived barriers preventing pharmacists from performing discharge counselling, and to determine the relative frequency of barriers and associated time expenditures...

OBJECTIVE: Automatic therapeutic substitution (ATS) is a mechanism that, upon patient hospitalization, prompts the pharmacist to exchange an equivalent formulary drug for a nonformulary medication, typically without prescriber contact. In facilities utilizing ATS, there is the possibility that physicians and patients may be unaware of the substitution, potentially leading to drug-drug interactions, therapeutic duplication, and/or increased patient expense following discharge should the original regimen not be resumed...

BACKGROUND: This study was designed to determine risk factors and potential harm associated with medication errors at hospital admission. METHODS: Study pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651 adult medicine service inpatients with 5,701 prescription medications. Discrepancies resulting in order changes were considered errors. Logistic regression was used to analyze the association of patient demographic and clinical characteristics including patients' number of pre-admission prescription medications, pharmacies, prescribing physicians and medication changes; and presentation of medication bottles or lists...

BACKGROUND: Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs). OBJECTIVE: To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge. DESIGN: Randomized, controlled trial with concealed allocation and blinded outcome assessors...

BACKGROUND: When patients are admitted to, and discharged from hospital there is a high chance of discrepancies and errors occurring during the transfer of patients' medication information. This often causes drug related problems. Correct and fast communication of patients' medication information between community pharmacy and hospital is necessary. OBJECTIVE: To investigate the number, type, and origin of discrepancies within discharge documents and between discharge documents and information in the pharmacy computer system, concerning the medication of patients living independently when they are discharged from hospital...

Medication reconciliation arose as the solution to the well-documented patient safety problem of unintentionally introducing changes in patients' medication regimens due to incomplete or inaccurate medication information at transitions in care. Unfortunately, medication reconciliation has often been misperceived as a superficial administrative accounting task with a "pre-occupation with completing forms," resulting in the implementation of ineffective processes. In this article, the authors briefly review the evidence supporting medication reconciliation but focus more on key practical questions regarding the elements of an effective medication reconciliation process: what it should consist of, where and when it should occur, who should carry it out and how hospitals should implement it...

Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated...

BACKGROUND: Medication reconciliation aims to correct discrepancies in medication use between health care settings and to check the quality of pharmacotherapy to improve effectiveness and safety. In addition, medication reconciliation might also reduce costs. OBJECTIVE: To evaluate the effect of medication reconciliation on medication costs after hospital discharge in relation to hospital pharmacy labor costs. METHODS: A prospective observational study was performed...

BACKGROUND: Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. OBJECTIVE: To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. DESIGN, PARTICIPANTS: We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study...

Medication reconciliation identifies and resolves unintentional discrepancies between patients' medication lists across transitions in care. The purpose of this review is to summarize evidence about the effectiveness of hospital-based medication reconciliation interventions. Searches encompassed MEDLINE through November 2012 and EMBASE and the Cochrane Central Register of Controlled Trials through July 2012. Eligible studies evaluated the effects of hospital-based medication reconciliation on unintentional discrepancies with nontrivial risks for harm to patients or 30-day postdischarge emergency department visits and readmission...